Provider Demographics
NPI:1588611842
Name:INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER, INC.
Entity Type:Organization
Organization Name:INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER, INC.
Other - Org Name:LSA RECOVERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GERSTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:929-273-7601
Mailing Address - Street 1:1623 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1209
Mailing Address - Country:US
Mailing Address - Phone:718-375-1200
Mailing Address - Fax:718-382-3358
Practice Address - Street 1:1623 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1209
Practice Address - Country:US
Practice Address - Phone:718-375-1200
Practice Address - Fax:718-382-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 2084P0800X
NY6989100A251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00245318Medicaid
NYW01831Medicare PIN